Les thérapies basées sur l’acceptation et la pleine conscience Acceptance and mindfulness-based cognitive-behavioral therapies

Résumé

La thérapie cognitivo-comportementale (TCC) est une des approches principales en psychothérapie. Elle enseigne au patient à faire le lien entre les cognitions dysfonctionnelles et les comportements mésadaptés et à réévaluer les biais cognitifs qui maintiennent les symptômes en utilisant des stratégies telles que le questionnement socratique. La TCC évolue constamment afin d’en améliorer l’efficacité et l’accessibilité. Dans la dernière décennie, des approches de plus en plus populaires basées sur la pleine conscience et l’acceptation sont proposées. Elles ne visent pas la modification des pensées même si celles-ci peuvent paraître biaisées et dysfonctionnelles, mais cherchent plutôt à changer la relation de l’individu à ses symptômes. L’efficacité de ces approches commence à être documentée. Cet article vise à présenter le contexte historique qui a permis l’émergence de ce courant, les points de convergence et de divergence avec l’approche cognitivo-comportementale traditionnelle ainsi qu’une brève présentation des différentes thérapies basées sur l’acceptation et la pleine conscience.

Mots-clés :

• thérapie cognitivo-comportementale,
• acceptation,
• pleine conscience,
• troisième vague

Abstract

Cognitive behavioral therapy (CBT) is one of the main approaches in psychotherapy. It teaches the patient to examine the link between dysfunctional thoughts and maladaptive behaviors and to re- evaluate the cognitive biases involved in the maintenance of symptoms by using strategies such as guided discovery. CBT is constantly evolving in part to improve its’ effectiveness and accessibility. Thus in the last decade, increasingly popular approaches based on mindfulness and acceptance have emerged. These therapies do not attempt to modify cognitions even when they are biased and dysfunctional but rather seek a change in the relationship between the individual and the symptoms. This article aims to present the historical context that has allowed the emergence of this trend, the points of convergence and divergence with traditional CBT as well as a brief presentation of the different therapies based on mindfulness meditation and acceptance. Hayes (2004) described three successive waves in behavior therapy, each characterized by “dominant assumptions, methods and goals”: traditional behavior therapy, cognitive therapy and therapies based on mindfulness meditation and acceptance. The latter consider that human suffering occurs when the individual lives a restricted life in order avoid pain and immediate discomfort to the detriment of his global wellbeing. These therapies combine mindfulness, experiential, acceptance strategies with traditional behavior principles in order to attain lasting results. There are significant points of convergence between traditional CBT and therapies based on mindfulness meditation and acceptance. They are both empirically validated, based upon a theoretical model postulating that avoidance is key in the maintenance of psychopathology and they recommend an approach strategy in order to overcome the identified problem. They both use behavioral techniques in the context of a collaborative relationship in order to identify precise problems and to achieve specific goals. They focus on the present moment rather than on historical causes. However, they also present significant differences: control vs acceptance of thoughts, focus on cognition vs behavior, focus on the relationship between the individual and his thoughts vs cognitive content, goal of modifying dysfunctional beliefs vs metacognitive processes, use of experiential vs didactic methods, focus on symptoms vs quality of life, strategies used before vs after the unfolding of full emotional response. The main interventions based on mindfulness meditation and acceptance are: Acceptance and Commitment Therapy, Functional Analytic Therapy, the expanded model of Behavioral Activation, Metacognitive Therapy, Mindfulness based Cognitive Therapy, Dialectic Behavior Therapy, Integrative Behavioral Couples Therapy and Compassionate Mind Training. These are described in this article. They offer concepts and techniques which might enhance therapeutic efficacy. They teach a new way to deploy attention and to enter into a relationship with current experience (for example, defusion) in order to diminish cognitive reactivity, a maintenance factor for psychopathology, and to enhance psychological flexibility. The focus on cognitive process, metacognition as well as cognitive content might yield additional benefits in therapy. It is possible to combine traditional CBT with third wave approaches by using psychoeducation and cognitive restructuring in the beginning phases of therapy in order to establish thought bias and to then encourage acceptance of internal experiences as well as exposure to feared stimuli rather than to continue to use cognitive restructuring techniques. Traditional CBT and third wave approaches seem to impact different processes: the former enhance the capacity to observe and describe experiences and the latter diminish experiential avoidance and increase conscious action as well as acceptance. The identification of personal values helps to motivate the individual to undertake actions required in order to enhance quality of life. In the case of chronic illness, it diminishes suffering by increasing acceptance. Although the evidence base supporting the efficacy of third wave approaches is less robust than in the case of traditional cognitive or behavior therapy, therapies based on mindfulness meditation and acceptance are promising interventions that might help to elucidate change process and offer complementary strategies in order to help patients.

Keywords:

• cognitive-behavioral therapy,
• acceptance,
• mindfulness,
• third wave